Occams’s Razor Couldn’t Cut It: A Tale of Two Headaches
Abstract Number: S-58
Abstract Type: Case Report/Case Series
Occam’s razor advises that a patient’s symptoms should be accounted for using the fewest number of causes. This is sometimes paraphrased as “don’t give the patient two diseases when one will do.” We present a patient that developed both a post-dural puncture headache (PDPHA) and a concurrent headache due to lymphocytic adenohypophysitis (LAH).
Case Report: A 34 yo G1P0 with a 36.3 wk twin gestation, requested labor analgesia at 3 cm dilation. Her medical history, medications, and laboratory values were unremarkable. A combined spinal-epidural (CSE) was attempted at L3-4 using a standard CSE kit with LOR to air. Immediately upon obtaining the LOR, a dural puncture was noted. The epidural needle was removed, and a second successful CSE was placed at L2-3 resulting in excellent pain relief throughout labor and delivery.
About 4 h after CSE placement, the patient complained of a headache (HA) which had begun after the initial CSE attempt. No diagnostic/therapeutic interventions occurred until after delivery, when she was noted to have a severe positional, posterior HA radiating into the neck. Nausea, photophobia, and dizziness were present. Her neurologic exam and vital signs were normal. Initially she opted for conservative therapy with i.v. caffeine and a scheduled ibuprofen dose, which resulted in reasonable pain relief. Ultimately, however, she requested an epidural blood patch (EBP). The EBP was performed using 20 ml of blood, and provided immediate improvement in her HA. She was discharged four days post-delivery, only to be re-admitted through the ER two days later complaining of recurrent HA with a questionable positional component. Again her vital signs, neurologic exam, and laboratory studies were unremarkable. Cranial computerized tomography revealed an enlarged pituitary gland with a 1 cm mass consistent with hemorrhage, and the patient was admitted for possible pituitary apoplexy. However, all endocrine parameters remained in the normal range for a post-partum female. A clinical diagnosis of LAH was made, and the patient was treated with high-dose steroids leading to an almost immediate resolution of symptoms, and to eventual shrinkage of the pituitary.
Discussion: LAH is an inflammation of the pituitary secondary to autoimmunity. It is most common in women (80 – 90% of cases) particularly in the peripartum period (50 -75% of cases). As such, it should appear in any differential diagnosis of post-partum HA. Non-positional headache with concomitant nausea and vomiting are common symptoms. Resolution of symptoms and pituitary swelling with steroid therapy are consistent with a diagnosis of LAH. In this patient, two different HAs were present as suggested by the temporary but marked relief obtained with appropriate therapy for PDPHA, followed by a rapid recrudescence of HA symptoms. Hickam’s dictum (“The patient can have as many diseases as they damn well please”) appears to have been operative in this case.